Operable breast cancer
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Operable breast cancer Clinical pathway only valid in : Campus : SA Specialty : Gynaecology Gynaecologie Date of implementation: 18/06/2012 Date of expiration : 18/07/2013 Document Manager: Verheyden Gerda Attending Physician : van Dam Peter Operaties Zorg Versie: 2.0 Objective: Pre-operative: patient is in optimal physical and psychosocial condition before the intervention- optimal planning of clinical care Postoperative: patient receives high quality and safe post-operative care and aftercare Inclusion criteria Exclusion criteria Comment: the hospital ward is notified by means of registration forms about the patient’s admission to the clinical pathway Patiënts with primary operable breast cancer Metastases Pre-operative discharge criteria Assurance: Evaluation criteria Physician o Clinical staging / clinical TNM o Intervention date within 15 days of diagnosis o Trusting relationship o Explanation future prospects o Consult oncologist Breast care nurse: o Consult at time of diagnosis/ pre-operative o Check understanding of information Social services o Pre-operative consult for high risk patients Psychologist o Pre-operative consult for risk patients Clinical indicators o Tripple assessment o Eusoma indicators: 10 compulsory indicators Process indicators o Stagings test before intervention o True cut biopsy within 48h of 1st consult o Pre-operative Multidisciplinary Oncological Committee (MOC) o Diagnosis within 5 labor days o Pre-operative consult breast care nurse Financial indicators o Number of patients o Average length of hospital stay Patient satisfaction Latest version can be consulted at : http://portaal.gza.be - Kennisbank – Procedureboeken – Zorgpaden - Operable breast cancer 2.0 P.1/12 Link to: - - Clinical pathway phase link Definitions link Latest version can be consulted at : http://portaal.gza.be - Kennisbank – Procedureboeken – Zorgpaden - Operable breast cancer 2.0 P.2/12 Admission phase Day -14 until day -10 Day -10 until day -7 Day -6 until day -2 / 1 Critical indicators Key interventions Consult within 24 h Consult breast clinic True cut within 48 h True cut Time 1st consult - diagnosis Pre-operative MOC Medical Care Breast clinic consultation Interpretation bilateral mammography – ultrasound Breast MR Imaging Appointment oncological center Scheduling biopsy Pre-admission medication Communicate diagnosis Communicate further planning Pre-operative diagnostic examinations Results staging tests Scheduling intervention Result pre-operative MOC Pre-admission medication Stop oral anti-coagulation day -7 Present at time of diagnosis communication Review diagnosis/ prognosis Team introduction Illustrate information leaflet Emotional support Appointments stagings tests Liver ultrasound Chest Xray Bone scan Venipuncture CA 15.3 Analysis health performance score using the “health meter” Liaison function Optional consult Available for consult Normal diet or pre-admission diet Scheduling Sentinel Guide wire biopsy True cut biospsy Vacuum assisted biopsy in case of microcalcifications Pre-operative tests link Staging tests Liver ultrasound Chest Xray Medication Nursing care Nursing specialist Introduction breast care nurse Scheduling true cut biopsy Scheduling tests Emotional support Oncocoach Social services Psychology Nutrition Physiotherapy/Mobilisation Tests Normal diet or pre-admission diet Health performance score (Health meter) Referral self-help group Emotional support Discussion/review surgical intervention Treatment Clincal pathway Normal diet or pre-admission diet Latest version can be consulted at : http://portaal.gza.be - Kennisbank – Procedureboeken – Zorgpaden - Operable breast cancer 2.0 P.3/12 Bone scan Venipuncture CA 15.3 Sentinel lymph node Material Information/Education Discharge preparation Information leaflet Intervention Aftercare Wire-guided localization / sentinel MR Imaging/ mammography Breast cancer Check discharge indicators Pre-operative MOC concluded Date of intervention known Check pre-admission Latest version can be consulted at : http://portaal.gza.be - Kennisbank – Procedureboeken – Zorgpaden - Operable breast cancer 2.0 P.4/12 Inclusion criteria operative phase Exclusion criteria operatieve fase Comment: the hospital ward is notified by means of registration forms about the patient’s admission to the clinical pathway Patiënts with primary operable breast cancer Metastases Pre-operative discharge criteria Assurance: evaluation criteria Physician o Had an informative conversation with the patient, patient is informed about aftercare and time of discharge. o Has seen cytology results o Follow-up appointment o Appointment for suture removal Oncologist (cooperating doctors) o 2nd contact moment about aftercare o Appointment adjuvant medical treatment planning visit Breast care nurse: o Coordination and planning further course o Checklist - patient understood aftercare information - appointment adjuvant medical treatment planning visit - information about social services/psychologist - physiotherapy appointment - self-care/ information about prosthesis - information about self-help groups o Information about individual therapy, counseling programs etc. o Check planning visit Social services o Organized homecare services if necessary o Information Psychologist o Pre-operative consult if risk patient Clinical indicators o Tripple assessment o Eusoma indicators: 10 compulsory indicators Process indicators o Stagings test before intervention o True cut biopsy within 48h of 1st consult o Pre-operative Multidisciplinary Oncological Committee (MOC) o Diagnosis within 5 labor days o Pre-operative consult breast care nurse Financial indicators o Number of patients o Average length of hospital stay Patient satisfaction Latest version can be consulted at : http://portaal.gza.be - Kennisbank – Procedureboeken – Zorgpaden - Operable breast cancer 2.0 P.5/12 Admission phase Day -1 Critical indicators Day O Day 1 Day 2 Pain core < 3 Patient mobilisation Pain score < 3 Arm mobilisation Patient mobilisation Pain score < 3 Key interventions Admission Sentinel lymph node Surgical intervention Medical care Pre-operative anesthesia consult Pre-admisson medication Surgical intervention Medication Pre-admission medication (optional) ------------------------------------Pre-operative medication Temesta -------------------------------------Fluid management Standing order remaining fluid 1l Hartmann IV over 12 h -----------------------------------Pain management Paracetamol 1g 100ml Perf. Fresenius 100ml/30min 1x/hu 100 ml IV Drain removal Social services Prosthesis information Check bandage Pre-admission medication restart --- -------------------------------Pain management Paracetamol 1g tablet 1x/6h standing order -------------------------------------PONB Protocol PONB link -------------------------------------20h: Sleep medication if needed Loramet 2 mg PO < 60 y Loramet 1 mg PO >60 y Pre-admission medication -------------------------------------Pain management Paracetamol 1g tablet 1x/6h on demand -------------------------------------20h: Sleep medication if needed Loramet 2 mg PO < 60 y Loramet 1 mg PO >60 y Escape Tramadol100mg ampul 1x/perf 1 ampul IV + Litican 2ml ampul 1x/perf 1 ampul IV(L) + Natriumchloride 0,9% 100ml Minibag 100ml/30min 1x/6h IV -------------------------------------PONB Protocol PONB link Latest version can be consulted at : http://portaal.gza.be - Kennisbank – Procedureboeken – Zorgpaden - Operable breast cancer 2.0 P.6/12 -------------------------------------- Nursing care Check ambulant tests - Mammography/ US - Chest Xray - Venipuncture - ECG -------------------------------------Nurse patient history: - Norton Score+ length + weight - Patient profile - Pre-admission medication - Diet Pre-opertative preparation - Check ID bracelet - Operation gown - Identification tags - Removal: dental prostheses, piercings, jewelry -------------------------------------Hygiene - Shower or washbasin -------------------------------------Vital parameters - Blood pressure, pulse -------------------------------------Post-operative checks Every 2h during 8h Thereafter, every 4h during 8h - IV drip - VAS Nausea - VAS Pain - Consciousness Post-operative parameters Every 2h during 8h Thereafter, every 4h during 8h - Blood pressure, pulse Post-operative wound care Every 2h during 8h Thereafter, every 4h during 8h - Check drain: color, volume, air vacuity Secretions Check spontaneous miction Vital parameters Blood pressure and pulse before morning nursingTempature 2x/day and when necessary -------------------------------------Hygiene - Bed bath - Washing private parts - Assistance with wash basin -------------------------------------Check 2x/day and if needed - VAS pain - VAS nausea - Consciousness -------------------------------------Wound care Check 2x/day and if necessary - Bandage - Drain -------------------------------------Mobility First: standing up and walk in the room Vital parameters Blood pressure and pulse before morning nursingTempature 2x/day and when necessary -------------------------------------Hygiene - Washing private parts - Assistance with wash basin -------------------------------------Check 2x/day en if needed - VAS pain - VAS nausea - Consciousness -------------------------------------Wondzorg Controle 2X/d en z.n.: - Sterile dry dressing - Remove drain if < 20 ml /24 h -------------------------------------- Latest version can be consulted at : http://portaal.gza.be - Kennisbank – Procedureboeken – Zorgpaden - Operable breast cancer 2.0 P.7/12 Nursing specialist Information: - surgical intervention - care pathway Emotional support Referral: social services, psychologist Information: - course of the surgery - wound Emotional support Information: - self-help groups - prostheses - revalidation Optional after contacting breast nurse: Contact social services: - Delineate domestic setting - Professional status - Hospitalisation insurance Optional consult Normal diet Optional consult Normal diet Contact breast nurse Oncocoach Social services Psychology Nutrition Information: intervention date Emotional support Optional consult Normal diet Optional consult Fasting Fluids allowed 6h after surgery Physiotherapy/ Mobilisation Tests Material Information/Education Discharge preparation Arm mobilisation after axillary lymph node dissection (ALND) Breast prosthesis Information leaflet Appointment for follow-up Adjuvant treatment planning visit Latest version can be consulted at : http://portaal.gza.be - Kennisbank – Procedureboeken – Zorgpaden - Operable breast cancer 2.0 P.8/12 Admission phase Day 3 Day 4 Day 5 Critical indicators Pain < 3 Pain < 3 Pain < 3 Anatomical pathology report MOC Psycho-social consultation: - breast care nurse - psychologist - social services Key interventions Medical care Informative conversation Planning discharge date Informative conversation Planning discharge date Medication Pre-admission medication -------------------------------------Pain management Dafalgan Forte 1g effervescent tablet 1x/6u 1 tablet on demand -------------------------------------20u: Sleep medication if needed: Loramet 2 mg PO < 60 y Loramet 1 mg PO >60 y Vital parameters - Blood pressure and pulse before morning nursing - Temperature 2x/day and if needed -------------------------------------Hygiene - Assistance with washbasin -------------------------------------Check 2X/d and if needed - VAS pain - VAS nausea - VAS fatigue - Consciousness Thuismedicatie -------------------------------------Pain management Dafalgan Forte 1g effervescent tablet 1x/6u 1 tablet on demand -------------------------------------20u: Sleep medication if needed: Loramet 2 mg PO < 60 y Loramet 1 mg PO >60 y Vital parameters - Blood pressure and pulse before morning nursing - Temperature 2x/day and if needed -------------------------------------Hygiene - Assistance with washbasin -------------------------------------Check 2X/d and if needed - VAS pain - VAS nausea - VAS fatigue - Consciousness Nursing care Day 6 Informative conversation Planning discharge date Follow-up appointment Thuismedicatie -------------------------------------Pain management Dafalgan Forte 1g effervescent tablet 1x/6u 1 tablet on demand -------------------------------------20u: Sleep medication if needed: Loramet 2 mg PO < 60 y Loramet 1 mg PO >60 y Vital parameters - Blood pressure and pulse before morning nursing - Temperature 2x/day and if needed -------------------------------------Hygiene - Assistance with washbasin -------------------------------------Check 2X/d and if needed - VAS pain - VAS nausea - VAS fatigue - Consciousness Latest version can be consulted at : http://portaal.gza.be - Kennisbank – Procedureboeken – Zorgpaden - Operable breast cancer 2.0 P.9/12 Nursing specialist Oncocoach Social services Wound care Check 2x/day and if needed: - Sterile dry dressing - Remove drain if < 20ml/24h Wound care Check 2x/day and if needed: - Sterile dry dressing - Remove drain if < 20ml/24h Wound care Check 2x/day and if needed: - Sterile dry dressing - Remove drain if < 20ml/24h Information: - surgical intervention - hospitalisation course Emotional support Contact psychologist/ social services Information - surgical intervention - additional tests - Emotional support Information: - course of the surgery - wound - self-help groups (+perhaps addresses) Emotional support Adjust prothesis in case of mammectomy - Follow-up consult Optional consult after visit of the breast nurse Psychology Nutrition Physiotherapy/ Mobilisation Normal diet Psychosocial consultation 1X/week Fasting Fluids allowed 6h after surgery Post-operative bedrest, depending on vital parameters Systematic application for physiotherapy in case of ALND Tests Material Information/Education Start arm mobilisation in bed in case of ALND Continue arm mobilisation Naboram visit (patient supporting group involved in fitting breast prothesis) Providing written information on chemotherapy / radiotherapy optional Breast prosthesis Latest version can be consulted at : http://portaal.gza.be - Kennisbank – Procedureboeken – Zorgpaden - Operable breast cancer 2.0 P.10/12 Wound care Hygiene Discharge criteria satisfied Discharge preparation Multidisciplinary team Physicians Departments Name Medical coordinator Gynaecologic oncology Gynaecologic oncology Gynaecologic oncology P. van Dam Anesthesiology Van Houwe Anatomic pathology P. Vermeulen C. Colpaert L. Verkinderen J. Hauspy Radiologiy A. De Schepper A. Bernaerts Medical oncology L. Dirix A. Prové Radiotherapy C. De Pooter G. Buelens R. Weytjens Reconstructive surgery J. Vanoorbeek Physiotherapy K. Deckers Genetics M. De Smedt Psychiatry A. Dewit Gynaecology Departments Names Nurse Gynaecology Gynaecology C. Martens N. Becuwe Psychosocial Psychology S. Van Gaelen Nurse Social worker Social worker Nurse Social services Social services Social services Social services T. De Backer E. De Jongh K. Moerman I. Deschacht Breast care nurse Breast care nurse Breast care nurse Nursing staff Nursing staff Nursing staff A. Van As C. Guiette C. Dhaenens Paramedical Physiotherapist Physiotherapist Physiotherapy Physiotherapy R. Hofkens K. Proost Oncology dietitian Oncology nutrition J. Liekens Datamanager Cancer registration I. Daniels IT-coördinator IT M. Mertens Clinical pathway coördinator Cell management support G. Verheyden Extern Naboram J. Van Wiemeersch Latest version can be consulted at : http://portaal.gza.be - Kennisbank – Procedureboeken – Zorgpaden - Operable breast cancer 2.0 P.11/12 Approval Approved by: van Dam Peter [Goedgekeurd Door 2] [Goedgekeurd Door 3] [Goedgekeurd Door 4] [Goedgekeurd Door 5] Ref. nr.: - Latest version can be consulted at : http://portaal.gza.be - Kennisbank – Procedureboeken – Zorgpaden - Operable breast cancer 2.0 P.12/12
